Assessment Criteria
1. Quality of Care
- Documented investigation appropriate to patient's complaint/condition
- Appropriate diagnoses are reached
- Management plan and medication prescribed are appropriate to condition being treated
- Indications for surgical and other procedures are documented and appropriate
- Adequacy of treatment of both acute and chronic conditions
- Counselling and psychotherapeutic sessions are appropriately indicated
- Utilization of support and community resources
- Practice guidelines are being followed
- Evidence of appropriate investigations and follow-up of results
- Assessment of lifestyle and preventive health issues
- Arrangements are made for the physician's patients to be cared for in his/her absence
- Emergency problems are dealt with promptly and effectively
2. Medical Records
- Adequate notes for reader to follow present management
- Stress quality of legibility
- Patient identity is clearly evident on each chart component
- Describe organization within charts, retrieval of items
- Use of standard forms (cumulative patient profile, flow sheets, medications, history summary, etc.)
- S.O.A.P. type or narrative notes covering all areas
- Diagnosis and treatment plan are clearly stated
- Allergies and drug reactions clearly documented, as well as dates of immunizations
- Documentation of medications - type, duration, evidence of regular review
- Significant positive and negative findings are recorded
- System for acknowledgement and follow-up of abnormal test results
- Retention of pathology reports, hospital discharge summaries, operative notes, etc.
- Use of pediatric growth charts and Saskatchewan Prenatal Forms
- Documented evidence that periodic general assessments are performed
- Documented evidence that lifestyle and health maintenance issues are discussed
- Identification of physicians making chart entries
- Evidence of progress notes for management of chronic conditions
- Recording in charts of significant telephone advice given
3. Physical Facilities and Practice Organization
a. General Office Facilities
- Adequacy of total area - describe size, design, atmosphere, cleanliness, maintenance
- Accessibility - wheelchair, parking, etc.
- Waiting rooms - comfort, current reference and reading materials, toys
- Examining rooms - adequate size and equipment, private
- Washrooms - accessibility, cleanliness
b. Telephone System
- Number of incoming lines and available staff for answering
- Are fax, e-mail services available
- Scheduled call back time or other means of returning calls
- System to ensure incoming messages are appropriate directed and acknowledged
- Physician's contactability during office hours as well as after hours on-call system
c. Appointment System
- Does it satisfactorily accommodate patients
- Booking rate (patients per hour) for new or full assessments
- Booking rate (patients per hour) for repeat patients
- Waiting time for appointments, waiting time in waiting room
- Does physician keep to appointment schedule
- System for urgent or emergency appointments
- Is a Day Sheet maintained - manual or computerized
- Mechanism to ensure patients are not missed in the waiting room
d. Filing System
- Chart types - family or individual
- Electronic Medical Records
e. Medical Instruments and Equipment
- Ensure equipment, including minor surgical materials, is appropriate to the type of practice
- Appropriate sterilization procedures in place
- System for managing biomedical waste and medication disposal
f. Drug Supplies and Samples
- Ensuring appropriate drugs are available and appropriately stored
- Maintaining current list of drugs on hand, monitoring expiration dates
- Narcotic/controlled drug security
g. Emergency Facilities
- Emergency tray/cart - appropriately stocked, centrally stored, readily available
- Availability of Adrenalin and appropriate syringes for administration
- Presence of 9-1-1 service in community or alternate emergency personnel
- List of minimal drugs and supplies in the clinic, monitoring of expiration dates
- Knowledge of office staff in the event of an emergency of disaster
h. Laboratory Investigations
- Type of investigations available
- Are they accessible on-site or close by
i. Personnel
- Number of staff persons, duties and training
- Documented plans in place for handling emergencies in the office
- Regular staff meetings/communications
- Documented job descriptions and office policies
j. Walk-in Clinics
- Determine whether physician provides ongoing or episodic care
- Evidence of patient education regarding importance of regular visits to their family physician
- Determine patients' family physician and document information in charts
- Mechanism for provision of information to patients' family physician
- System for handling non-urgent referrals
- Provision for after hours coverage
- Establishment of clinic policies and standards for employed physicians
k. Miscellaneous Observations
- System for handling telephone requests for repeat prescriptions from patient or pharmacy
- System for handling incoming reports, test results
- System for handling consultations and referrals
- Policy in place when a patient is dressing/undressing, is appropriate draping provided
- Accessibility of reference materials for physicians and patients - hardcopy, electronic
L. Health Information Protectoin Act Compliance (HIPA)
- Posters/brochures posted in clinics re privacy / patient confidentiality
- Appointment of a privacy officer to deal with issues relating to patient confidentiality and HIPA
- Security of patient records clinic
- Staff and signed confidentiality agreements
